Nursing assessment

Nursing assessment

Exploitation and manipulation

Belligerent; argumentative

Lack of remorse

Unable to delay gratification

Low frustration tolerance

Inconsistent work and or academic performance

Failure to conform to societal norms

Impulsive; reckless

Inability to form lasting relationship

Nursing Diagnosis

Risk for self-mutilation

Risk factors: History of self-injurious behavior; history of inability to plan solutions; impulsivity; irresistible urge to damage self; feels threatened with loss of significant relationship

Risk for suicide/Risk for self or other directed violence

Risk factors: History of suicide attempts; suicidal ideation; suicidal plan; impulsiveness; childhood abuse; fears of abandonment; internalized rage

Risk for other-directed violence

Risk factors: Body language (e.g., rigid posture, clenching of fists and jaw, hyperactivity, pacing, breathlessness, threatening stances); history of childhood abuse; impulsivity; transient psychotic symptomatology

Chronic low-self esteem

Dependent on others; excessively seeks reassurance; manipulation of others;inability to tolerate being alone

Defensive coping/Complicated grieving

Depression; persistent emotional distress; rumination; separation distress; traumatic distress; verbalizes feeling empty; inappropriate expression of anger

Impaired social reaction

Alternating clinging and distancing behaviors; staff splitting; manipulation

Ineffective health maintenance

Disturbed personal identity

Feelings of depersonalization and derealization

Anxiety (Severe to panic)

Transient psychotic symptoms (disorganized thinking; misinterpretation of the environment); increased tension; decreased perceptual field


Realistic goal setting

Identifies origin of anger

Seeks out staff when urge to engage in violence/anger/self-harm